Provider Demographics
NPI:1881709285
Name:WILLIS, MANDY LYNNE (PT)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:LYNNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MANDY
Other - Middle Name:LYNNE
Other - Last Name:ZOLCIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 392573
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-9573
Mailing Address - Country:US
Mailing Address - Phone:440-255-9553
Mailing Address - Fax:440-255-9563
Practice Address - Street 1:8836 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4361
Practice Address - Country:US
Practice Address - Phone:440-255-9553
Practice Address - Fax:440-255-9563
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 10745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH41444421Medicare ID - Type Unspecified